This presentation was made by Tommy Wilkinson, United-Kingdom, at the 4th meeting of the Joint DELSA/GOV-SBO Network on Fiscal Sustainability of Health Systems, held in Paris on 16-17 February 2015.

1. Seeking value: Experience from the UK’s National
Institute for Health and Care Excellence
Tommy Wilkinson
Advisor, NICE International
Copyright NICE International 2014
17th February 2015
4th Joint OECD Network on Fiscal
Sustainability of Health Systems

2. The vision: 5th July 1948
A National Health Service that:
• meets the needs of everyone
• is free at the point of delivery
• is based on clinical need, not ability to pay

3. • Doctors adopting new health technologies without adequate
evidence of their clinical and/or cost effectiveness
• Out of date technologies and services being used even though they
had been superseded by newer developments
• Lack of national clinical guidelines and many of the existing clinical
guidelines not updated and of poor quality.
• Postcode lottery inappropriate variation in access to care and care
standards
• (later) Prospect of significant reinvestment in the NHS: plan to grow
from about 6.5% to about 9% of GDP
Roll forward to the 90s…

4. The role of NICE
To improve outcomes for people using the NHS and other
public health and social care services by...
Producing evidence-based guidance and advice for
health, public health and social care practitioners.
Developing quality standards and performance
metrics for those providing and commissioning
health, public health and social care services
Providing a range of information services for
commissioners, practitioners and managers across
the spectrum of health and social care.

5. The NICE portfolio in 2014

6. “You have the right to drugs and treatments that
have been recommended by NICE for use in the
NHS, if your doctor says they are clinically
appropriate for you.” Jan 2009

7. What is a NICE Technology Appraisal?
• A review of clinical and economic
evidence leading to
recommendations on the appropriate
use of new and existing technologies
for the NHS
• A positive recommendation requires
providers to make the
recommendation available within
three months
• Opportunity to challenge decision
(formal appeal process)

8. Under controlled conditions and
compared to placebo:
• Is the drug safe?
• Does the drug do more good than
harm?
In routine clinical practice and
compared with existing treatments:
• Do the additional clinical benefits
justify the expected additional cost?
Drug
development
Regulatory
approval
Technology
Appraisal
Use in
healthcare system
Incorporating the
consideration of relevant
social value judgements

9. Determining value:
Incremental Cost-Effectiveness Ratio (ICER)
At NICE, health gain is expressed as quality adjusted life years
(QALYs) which allows us to calculate the cost per QALY for
any technology under consideration
costnew – costcurrent
health gainnew – health gaincurrent

10. Determining value:
Social Value Judgements
“Those developing clinical guidelines, technology appraisals or
public health guidance must take into account the relative costs and
benefits of interventions (their ‘cost effectiveness’) when deciding
whether or not to recommend them.” (Principle 2)
BUT
“Decisions about whether to recommend interventions should not
be based on evidence of their relative costs and benefits alone.
NICE must consider other factors when developing its guidance,
including the need to distribute health resources in the fairest way
within society as a whole.” (Principle 3)
NICE Social Value Judgements 2nd Edition 2008 http://www.nice.org.uk/media/C18/30/SVJ2PUBLICATION2008.pdf

11. Appraisal decision makingProbabilityofrejection
Cost per QALY
1
£10K £20K £30K £40K £50K
0
• Uncertainty ↑
• Features of condition
• Equity judgments ↕
• Availability of treatments
• Innovation ↓
• Uncaptured health gain
The Committee will want to be increasingly certain of the cost-effectiveness of a
technology as the impact of the adoption of the technology on NHS resources increases
(Para 6.2.14 Guide to Methods of Technology Appraisal, NICE 2013)

12. Therapeutic areas in technology appraisal topics
Blood & immune
Cancer
CardiovascularCentral nervous
system
Digestive system
Ear & nose
Endocrine,
nutritional &
metabolic
Eye
Gynaecology,
pregnancy & birth
Infectious diseases
Injuries, accidents &
wounds
Mental health &
behavioural
conditions
Mouth & dental
Musculoskeletal
Respiratory
Skin Urogenital

13. Most credible ICER for technologies
appraised by NICE 2007 – Sept 2013
£0
£20,000
£40,000
£60,000
£80,000
£100,000
£120,000
£140,000
£160,000
Recommended/ optimised Not recommended Recommended under EoL
TA114 TA296→

14. Decision outcomes
Decision Recommendations
Recommended in line
with marketing
authorization
333 62%
Optimised 97 18%
Only in research 26 5%
Not recommended 82 15%
Total 535 100%
Breakdown of all decisions contained in published NICE Technology Appraisals 1–321 (January 2000 to
October 2014). Note 6 withdrawn recommendations and 18 non-submissions are not included
80% of NICE
guidance is positive

15. Scientific
Rigour
Inclusiveness
Social
values
Transparency
IndependenceChallenge
Review
Support for
implementation
Timeliness
Accountability
for
reasonableness
NICE’s procedural principles for
guidance development